Safe and Effective Implementation of Telestroke in a US Community Hospital SettingKori Sauser-Zachrison, MD, MSc; Ernest Shen, PhD; Navdeep Sangha, MD; Zahra Ajani, MD; William P Neil, MD; Michael K Gould, MD, MS; Dustin Ballard, MD; Adam L Sharp, MD, MSA stepped-wedge cluster randomized trial of 10 community hospitals connected to 2 tertiary care centers via telestroke was implemented at each hospital incrementally over a 1-year period. Among 2657 patients, utilization of tissue plasminogen activator (tPA) increased from 6.3% to 10.9%, without a significant change in complication rates. Postintervention patients were more likely to receive tPA than were preintervention patients. Before implementation, 8 of the 10 community hospitals were significantly less likely to administer tPA than the highest-volume tertiary care center; however, after implementation, 9 of 10 were at least as likely to administer tPA.

Association of Unplanned Reintubation with Higher Mortality in Old, Frail Patients: A National Surgical Quality-Improvement Program AnalysisEfstathios Karamanos, MD; Nathan Schmoekel, DO; Dionne Blyden, MD; Anthony Falvo, DO; Ilan Rubinfeld, MDUnplanned postoperative reintubation increases the risk of mortality, but associated factors are unclear. In this retrospective study, patients older than age 40 years who underwent unplanned reintubation from 2005 to 2010 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. A total of 17,051 postoperative reintubations in adults were analyzed. Overall mortality was 29.4% (n = 5009). As American Society of Anesthesiology score increased from 1 to 5, reintubation was associated with a mortality of 12.1% to 41.6%, respectively. Similarly, increasing age decile was associated with increasing incidence of mortality. Among patients who underwent unplanned reintubation, older and more frail patients had an increased risk of mortality.

Standardizing Management of Adults with Delirium Hospitalized on Medical-Surgical UnitsClay Angel, MD; Kristen Brooks, MD; Julie FourieDelirium, common among inpatients aged 65 and older, is associated with multiple adverse consequences, including increased length of stay (LOS). However, delirium is frequently unrecognized and poorly understood. During a pilot from 9/2010 to 7/2012 (including 470 patients), a delirium management team included a redesigned role for consulting psychiatrists and a new clinical nurse specialist role. Electronic health record functions supported accurate problem list coding, referrals to the team, and standardized documentation. Average LOS decreased (8.5 to 6.5 days; p = 0.001) while average LOS for the Medical Center remained stable. The delirium team is an effective model that can be quickly implemented with few additional resources.

The Kaiser Permanente Northern California Adult Member Health SurveyNancy Gordon, ScD; Teresa Lin, MPHBetween 1999 and 2011 the adult Health Plan membership became better educated and less non-Hispanic white. Compared with 1999, in 2011, the prevalence of self-reported diabetes and hypertension significantly increased in most age groups. There was a significant increase in the percentage of those age 25-64 years who considered their health to be very good or excellent, primarily among those with higher education. There was an increase in the percentage of adults who indicated that physical or emotional health problems interfered at least moderately with their daily activities.

Trend of Decreased Length of Stay in the Intensive Care Unit (ICU) and in the Hospital with Palliative Care Integration into the ICUEluned Mun, MS, MSN, DNP, APRN-Rx, AGNP-BC, CCRN; Clementina Ceria-Ulep, PhD, RN; Lillian Umbarger, MD; Craig Nakatsuka, MDA comparison between pre- and postintervention data in the Intensive Care Unit (ICU), incorporating palliative care into the routine ICU workflow, showed positive trends in measured outcomes, including increased early identification of advance directives, code status, and goals of care along with a decrease in the ICU length of stay and hospital length of stay. The number of ICU family meetings and palliative care consultations increased.

Accreditation Council for Graduate Medical Education Core Competencies at a Community Teaching Hospital: Is There a Gap in Awareness?Mohammed Al-Temimi, MD, MPH; Michael Kidon; Samir Johna, MD, MACMPhysicians at the Kaiser Permanente Fontana Medical Center (480) were surveyed for their knowledge of ACGME core competencies before starting new residency programs. Of the 164 physicians who taught residents, 65 (39.7%) were unsure of their knowledge of the core competencies. However, most stated that they provided direct teaching to residents related to the knowledge, skills, and attitudes stated in each of the 6 competencies. Full-time faculty (teaching 10-12 rotations per year) were more likely to provide competency-based teaching. Discrepancy between knowledge of the competencies and acclaimed provision of competency-based teaching emphasizes the need for standardized teaching methods that incorporate the values of these competencies.

Anal Health Care BasicsJason Chang, MD; Elisabeth McLemore, MD, FACS, FASCRS; Talar Tejirian, MD, FACSAlthough countless patients suffer from anal problems, there tends to be a lack of understanding of anal health care. Common diagnoses include pruritus ani, anal fissures, hemorrhoids, anal abscess or fistula, fecal incontinence, and anal skin tags, most of which can be avoided by improving bowel habits. Adequate fiber intake is important for many reasons, including improving the quality of stool and preventing colorectal and anal diseases. This Special Report provides an overview of commonly encountered anal problems, their presentation, initial treatment options, and recommendations for referral to specialists.

Implementation of the YMCA Diabetes Prevention Program throughout an Integrated Health System: A Translational StudyRon Adams, MD; Christopher J Hebert, MD, MS; Linda McVey; Roger Williams, MEdThis observational study focused on engagement, persistence, recruitment, and adherence to the evidence-based YMCA Diabetes Prevention Program (DPP) of Greater Cleveland. Of the 2200 Medicare-eligible patients at risk of prediabetes, 351 (16.0%) responded by attending an information session; 228 enrolled in the DPP (11.3%) and persisted through at least Week 9. Because of the motivation and reinforcement provided to patients through YMCA-provided signs, brochures, and posters; a Web site; and in-person conversations with primary care physicians, an improvement occurred over the 1.7% who responded to the mailing for the previous DPP study.

Amniotic Fluid Embolism: Using the Medical Staff Process to Facilitate Streamlined CarePeter M Hession, MD; Cynthia J Millward, MD; Joyce E Gottesfeld, MD; Thomas F Rehring, MD; Kevin B Miller, MD; Paul M Chetham, MD; S Kel Muckleroy, MD; Christopher A Bates, MD; Harris W Hollis, Jr, MDThere are no published algorithmic approaches to the management of amniotic fluid embolism (AFE). Post hoc analysis of a complicated case of AFE resulted in development of a care pathway that addresses many of its major consequences. It is a template for use by any institution willing to implement a clinical pathway to treat AFE. It is accompanied by the remarkable case outcome that prompted its development.

Integrated Research and the Garfield Memorial National Research Fund—An Unobstructed ViewEd Thomas, RN, MBAIntegrated care has been discussed for many years. Those supporting and managing the Garfield Memorial National Research Fund believe a similar idea, integrated research, must be discussed and tested, beginning with rethinking the proposal format. This article elaborates on the enhanced proposal format, presenting powerful patient stories to demonstrate how integrated research can help deliver better patient care.

Trends in Type of Original Psoriasis Publications by Decade, 1960 to 2010Eric Sako, MD; Shannon Famenini, MD; Jashin J Wu, MDA literature review was performed using the keyword psoriasis in the MEDLINE database. All original psoriasis-related articles published at the beginning of each decade were searched and categorized by study type and topic. A total of 869 original psoriasis-related articles were found. The number of publications increased 18 fold over 5 decades. The immunology and pathogenesis of psoriasis was the most frequently researched topic (36%), and retrospective studies were the most common study type (37%). Recent highly published topics included biologic therapy, genetics, and psoriasis-associated cardiovascular disease.

Effectiveness of Cannabidiol Oil for Pediatric Anxiety and Insomnia as Part of Posttraumatic Stress Disorder: A Case ReportScott Shannon, MD, ABIHM; Janet Opila-Lehman, NDAnxiety and sleep disorders are often the result of posttraumatic stress disorder and can contribute to an impaired ability to focus and to demonstration of oppositional behaviors. These symptoms were present in our patient, a ten-year-old girl who was sexually abused and had minimal parental supervision as a young child under the age of five. Pharmaceutical medications provided partial relief; results were short-lived with major side effects. A trial of cannabidiol oil resulted in decreased anxiety and improvement in the quality and quantity of the patient’s sleep.

A General Pediatrics and Integrative Medicine Approach to Pervasive Refusal Syndrome: A Case ReportTido von Schoen-Angerer, MD, MPH; Elisabeth Helmschmidt, Dr Med; René Madeleyn, Dr Med; Reinhard Kindt, Dr Med; Christoph Möller, Prof Dr Med; Gunver Sophia Kienle, Dr Med; Jan Vagedes, Dr Med, MAPervasive refusal syndrome (PRS) describes children with social withdrawal who become unable to walk, eat, or care for themselves. A seven-year-old girl with symptoms most consistent with PRS and depression was admitted to a pediatric ward that integrates conventional pediatric and psychosomatic care with anthroposophic medicine. She was integrated into the activities of the ward and received massages, movement therapy, and color light therapy. After four weeks, she talked again, showed increased appetite, and supported herself when moved passively. She made a full recovery within four weeks after hospital discharge.

Carpal Tunnel Syndrome in Sarcoidosis: A Case Report of a Rare Neurologic ManifestationAjinkya Sonambekar, MD, MBBS; Nikhil Gupta, MD, MBBS; Akanksha Swadi, MD, MBBS; Laxmikant Ramkumarsingh Tomar, MD, MBBSSarcoidosis is a multisystemic inflammatory disease with myriad clinical manifestations. Neurologic involvement in sarcoidosis is uncommon. Peripheral neuropathic presentations include mononeuropathy, mononeuritis multiplex, and generalized sensory, motor, autonomic, and sensorimotor polyneuropathies. The authors report a case of carpal tunnel syndrome caused by sarcoidosis in a 30-year-old woman. Other causes of carpal tunnel syndrome were ruled out. The patient responded well to the standard line of corticosteroid treatment and wrist splinting. Carpal tunnel syndrome caused by sarcoidosis is a rare presentation. The mechanism of neurologic involvement in sarcoidosis is not clear.

An Ethics of Permission: A Response to the California End of Life Option ActCraig Nelson, PhD, CLSThe California End of Life Option Act law does not define morality, and reaching a moral understanding demands thorough reflection. An ethics of permission includes the importance of exercising professional tolerance in honoring clinicians who participate or who refuse to participate.

CLINICAL MEDICINE

Image Diagnosis: Hemorrhagic Bullae in a Primary Varicella Zoster Virus InfectionCátia Canelas, MD; João M Carvas, MD; Cristiana Sevivas, MD; Dina Carvalho, MDA 47-year-old man, 20 pack-year smoker, and heavy alcohol drinker, with an episode of pulmonary tuberculosis 10 years before, presented to the Emergency Department with 7 days of cough, mucous sputum, and abdominal pain. Additionally he presented with 5 days of pruriginous skin rash that started on the thorax but rapidly spread to the entire body, and with 3 days of fever.

EDITORIAL

Form Follows Function: A Functional Medicine OverviewPatrick Hanaway, MDIn the article on p 104, Plotnikoff presents a case report using an innovative systems-biology approach known as Functional Medicine. Treatment focused on the correction of common physiologic imbalances, along with lifestyle modifications in diet and nutrition. This case highlights a significant opportunity to move the focus of care toward root cause analysis, which, when combined with the power of lifestyle modification, can help to bend the cost curve and improve the value of care.

NARRATIVE MEDICINE

Her Glistening EyesAhmed Z Obeidat, MD, PhDOne day, as the end of our patient’s hospital stay neared, her son grasped my attention with these words: “Last night, she mentioned my name, touched my head, and pulled me close to her heart as if I were her baby again. She smiled and followed my steps around the room.” I was surprised to hear that she was so different at night. I inquired about that. Her son answered, “My mother became a night person after her stroke.”